How Do Medicare Managed Care Plans Work?

Medicare managed care plans function as Health Maintenance Organizations (HMOs), which means that subscribers must see physicians within a particular network and need referrals to visit out-of-network doctors or specialists. As a rule, their health-care benefits are also restricted in many other ways.

Individuals who reach the age of 65 and meet certain requirements qualify for Medicare, and others who are disabled and receive Social Security payments for a minimum of 24 months are also eligible for Medicare coverage. In such cases, the program covers all or some of their medical expenses within the established guidelines.

What These Plans Are Designed To Do

Medicare managed care plans are intended to reduce the cost of health care for seniors in the United States. With this in mind, some medical procedures necessitate pre-approval, and patients may also be required to use generic drugs and other less expensive methods of treatment. Obviously, those in charge of the program make certain health care decisions, rather than the doctors in the network or the patients under their care.

Medicare managed care plans are run by various government agencies, or private insurers that work on a contractual basis. The managers of specific programs will vary, depending on the plan chosen by the patient and the state where he or she resides. However, most of the guidelines under which they operate have been established by federal Medicare legislation.

These Plans Receive Mixed Reviews

Those in favor of Medicare managed care plans feel that the built-in cost-cutting saves taxpayer dollars and helps prevent waste. Others say that patients and their doctors should be in control, rather than insurance companies that have cost containment as their main goal (rather than providing patient care), and a third group maintains that emphasizing preventive care is the best way to control costs and help patients.